Butler County Auditor Roger Reynolds

Roger Reynolds, CPA
Butler County Auditor

Fuel Quality
Consumer Complaint


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FUEL QUALITY COMPLAINT FORM

Personal Information

Name:


First	Last

Home Address:

City:

State:

ZIP Code:

Day Phone:

Example: 513-422-5555

Evening Phone:

Example: 513-422-5555

Vehicle Information

Make:

Model:

Example: Camry

Year:

Station Information

Station Name:

Station Address:

City:

State:

ZIP Code:

If the address is unknown please describe location.

Example: "Corner of Niles and Dixie Highway."

Incident Report

Date Occurred

Example: 01/05/2001

Type of Gas:

Was the station notified of complaint? Yes No

Did vehicle require repairs? Yes No

If yes, please describe.

Cost of repairs:	$
Were you reimbursed for repairs? Yes No

Additional Information/Comments:

Butler County Administration Building: 130 High Street, 3rd & 4th floors, Hamilton, OH 45011 Phone: 513-887-3154 FAX: 513-887-3149
© 2010 Butler County Auditor